18 Basics of Diagnostic Coding Exam Questions and Answers Already Passed
diagnosis - Answers in medical coding, assessment and diagnostic statement are synonyms with
encounter - Answers any contact between a patient and a provider of service
assessment - Answers the physician's determination of what is or may be wrong with the patient based
on the findings from the H&P
chief complaint - Answers the abbreviation CC is a statement in the patient's own words that describes
why the person sought medical attention
manifestation - Answers the signs and symptoms of a disease
alphabetic index - Answers lists conditions, injuries, and diseases in alphabetical order by main terms,
modifying term, and subterms
ancillary diagnostic services - Answers services that support patient diagnoses (e.g., laboratory or
radiology services)
and/or - Answers in the context of the ICD-9-CM, the word and should always be interpreted as
chapters - Answers are broad sections of the ICD-9-CM coding manual grouped by disease or illness
code also - Answers is used when one or more codes are necessary to identify a given condition; also
know as use additional code
coding - Answers converting verbal or written descriptions into numeric and alphanumeric designations
conventions - Answers the abbreviations, punctuation, symbols, instructional notations, and related
entities that provide guidance to the medical assistant or coder in selecting an accurate and specific
code
diagnosis - Answers the determination of the nature of a disease, injury, or congenital defect
diagnosis statement - Answers the information about the diagnosis or diagnoses of the patient which
have been extracted from the medical documentation
etiology - Answers the cause of the disorder; a claim may be classified according to this
exclusion, excludes - Answers ____ terms are always written in italics, and the word ____ is often
enclosed in a box to draw particular attention to these instructions
history and physical examination - Answers H&P or HPE is an acronym for
ICD-9-CM - Answers the current system for classifying disease to facilitate collection of uniform and
comparable health information, for statistical purposes, and for indexing medical records for data
storage and retrieval
, principal diagnosis - Answers the initial identification of the condition or complaint the patient expresses
in the outpatient medical setting
see - Answers the term ____ must always be followed and is found in the Alphabetic Index, volumes 2
and 3; it is a direction given to a coder to look in another place
see also - Answers a direction given to the coder to look elsewhere if the main term or subterm(s) for
that entry are not sufficient for coding the information
see category - Answers a direction given to the coder to see a specific category (three-digit code); this
must always be followed
SOAP notes - Answers a system of charting that includes subjective findings, objective findings,
assessment, and plan
use additional code - Answers term that only appears in volume 1 in those subdivisions in which the user
should add further information by means of an additional code to give a more complete picture of the
diagnosis
with, with mention of, associated with - Answers in the context of the ICD-9-CM the terms ___, ___, and
___ dictate that both parts of the title be present in the statement of the diagnosis in order to assign the
particular code
three-digit - Answers the code consists of a ___ category code that represents a specific disease, illness,
condition, or injury within a general disease category
two - Answers up to ___ additional digits can be used, which add further definition and specificity
1 & 2 - Answers volume(s) used for diagnostic coding by hospitals, physicians, and all other providers of
service
1 - Answers also known as the Tabular Index, containing all of the diagnostic codes grouped into 17
chapters of disease and injury
chapters - Answers broad sections of the ICD-9-CM coding manual grouped by disease or illness
2 - Answers volume used by hospitals to code procedures and services performed in the hospital
environment
section - Answers also called a chapter
category - Answers also called a classification
subcategory - Answers fourth digit
subclassification - Answers fifth digit
diagnosis - Answers in medical coding, assessment and diagnostic statement are synonyms with
encounter - Answers any contact between a patient and a provider of service
assessment - Answers the physician's determination of what is or may be wrong with the patient based
on the findings from the H&P
chief complaint - Answers the abbreviation CC is a statement in the patient's own words that describes
why the person sought medical attention
manifestation - Answers the signs and symptoms of a disease
alphabetic index - Answers lists conditions, injuries, and diseases in alphabetical order by main terms,
modifying term, and subterms
ancillary diagnostic services - Answers services that support patient diagnoses (e.g., laboratory or
radiology services)
and/or - Answers in the context of the ICD-9-CM, the word and should always be interpreted as
chapters - Answers are broad sections of the ICD-9-CM coding manual grouped by disease or illness
code also - Answers is used when one or more codes are necessary to identify a given condition; also
know as use additional code
coding - Answers converting verbal or written descriptions into numeric and alphanumeric designations
conventions - Answers the abbreviations, punctuation, symbols, instructional notations, and related
entities that provide guidance to the medical assistant or coder in selecting an accurate and specific
code
diagnosis - Answers the determination of the nature of a disease, injury, or congenital defect
diagnosis statement - Answers the information about the diagnosis or diagnoses of the patient which
have been extracted from the medical documentation
etiology - Answers the cause of the disorder; a claim may be classified according to this
exclusion, excludes - Answers ____ terms are always written in italics, and the word ____ is often
enclosed in a box to draw particular attention to these instructions
history and physical examination - Answers H&P or HPE is an acronym for
ICD-9-CM - Answers the current system for classifying disease to facilitate collection of uniform and
comparable health information, for statistical purposes, and for indexing medical records for data
storage and retrieval
, principal diagnosis - Answers the initial identification of the condition or complaint the patient expresses
in the outpatient medical setting
see - Answers the term ____ must always be followed and is found in the Alphabetic Index, volumes 2
and 3; it is a direction given to a coder to look in another place
see also - Answers a direction given to the coder to look elsewhere if the main term or subterm(s) for
that entry are not sufficient for coding the information
see category - Answers a direction given to the coder to see a specific category (three-digit code); this
must always be followed
SOAP notes - Answers a system of charting that includes subjective findings, objective findings,
assessment, and plan
use additional code - Answers term that only appears in volume 1 in those subdivisions in which the user
should add further information by means of an additional code to give a more complete picture of the
diagnosis
with, with mention of, associated with - Answers in the context of the ICD-9-CM the terms ___, ___, and
___ dictate that both parts of the title be present in the statement of the diagnosis in order to assign the
particular code
three-digit - Answers the code consists of a ___ category code that represents a specific disease, illness,
condition, or injury within a general disease category
two - Answers up to ___ additional digits can be used, which add further definition and specificity
1 & 2 - Answers volume(s) used for diagnostic coding by hospitals, physicians, and all other providers of
service
1 - Answers also known as the Tabular Index, containing all of the diagnostic codes grouped into 17
chapters of disease and injury
chapters - Answers broad sections of the ICD-9-CM coding manual grouped by disease or illness
2 - Answers volume used by hospitals to code procedures and services performed in the hospital
environment
section - Answers also called a chapter
category - Answers also called a classification
subcategory - Answers fourth digit
subclassification - Answers fifth digit
